Kannaki.R v. The Directorate Of Medical And Rural Health Services
BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT DATED: 15.04.2024
CORAM:
THE HONOURABLE MS.JUSTICE R.N.MANJULA W.P.(MD)No.7086 of 2024 & W.M.P.(MD)No.6547 of 2024 R.Kannaki ... Petitioner vs.
1.The Director of Medical and Rural Health Services, Represented by its Director, DMS Complex 361, Anna Salai, Chennai - 600 006. 2.The Department of Treasuries and Accounts, Represented by its Commissioner, 3rd Floor, Perasiriyar K.Anbazhagan Maaligai, No.571, Anna Salai, Nandanam, Chennai - 600 035.
3.The District Collector, The Collectorate, Madurai District.
4.The United India Insurance Company Limited, Represented by its Branch Manager, Divisional Office VI, 5th Floor, P.L.A. Rathna Towers, 212, Anna Salai, Chennai - 600 006.
5.MD India Health Insurance TPA Private Limited, Represented by its Manager, Guna Complex, New Door No.443 & 445, Annasalai, Teynampet, Chennai - 600 0180. ... Respondents 1/12
Prayer: Writ Petition filed under Article 226 of the Constitution of India praying this Court to issue a Writ of Certiorarified Mandamus calling for the records pertaining to the impugned order in Ref: 010600/MP-21/12/2023 dated 09.11.2023 passed by the fourth respondent and quash the same as illegal and consequently direct the 4th respondent to provide enhancement of assistance to the petitioner under the New Health Insurance Scheme, 2016 in accordance with Clause 6(4) of G.O.Ms.No.160, Finance (Salaries) Department dated 29.06.2021 within the time stipulated by this Court.
For Petitioner :
Mr.O.R.Gokul Abimanyu For Respondents :
Mr.J.Ashok, Additional Government Pleader for R1 to R3 Mr.A.Shajahan, Standing Counsel for R4
O R D E R
Heard Mr.O.R.Gokul Abimanyu, learned counsel for the petitioner, Mr.J.Ashok, learned Additional Government Pleader for the respondents 1 to 3 and Mr.A.Shajahan, learned Standing Counsel for R4.
2. The petitioner has filed this writ petition praying to issue a Writ of Certiorarified Mandamus calling for the records in Ref: 2/12
010600/MP-21/12/2023 dated 09.11.2023 passed by the fourth respondent and quash the same and consequently direct the 4th respondent to enhance the reimbursement in accordance with Clause 6(4) of G.O.Ms.No.160, Finance (Salaries) Department dated 29.06.2021 (New Health Insurance Scheme, 2016).
3. The petitioner has been working as a secondary grade Teacher, Panchayat Union Elementary School at Melakottai, Thirumangalam, Madurai District. She got enrolled under the Tamil Nadu New Health Insurance Scheme, 2016, which provides for health care assistance on cashless basis for the employees of Departments of Government of Tamilnadu. The petitioner has undergone medical treatment for Double Vessel Coronary Artery Disease, Unstable Angina, Type 2 Diabetes Mellitus and Mild LV Dysfunction (LVEF-45%) by having admitted as an inpatient at Hannah Joseph Hospital, Madurai. Coronary Artery Angiography was performed on her on 09.12.2021. Pursuant to the above, the petitioner took follow up treatments as suggested by the medical experts. The petitioner had spent a sum of Rs. 3/12
3,40,748/- in toto. However, when she made her claim under the Scheme, she was sanctioned with Rs.1,05,200/- only.
4. In the authorisation letter dated 10.12.2021 issued by the fifth respondent, no reason was stated as to why the rest of the amount spent by the petitioner towards her treatment was denied. The petitioner has submitted all the medical bills to substantiate her claim for the amount spent by her. In the letter dated 29.07.2022 sent by the third respondent / District Collector also, no reason has been stated as to why her claim for reimbursement was limited.
5. The petitioner is said to have filed an appeal before the District Level Committee. However, the third respondent has advised the petitioner and like others to prefer an appeal before the State Level Committee. The petitioner has not filed any appeal before the the State Level Committee, but has simply addressed a letter to the Commissioner, Treasuries and Accounts Department, Nandanam, Chennai. Even the Commissioner, Treasuries and Accounts Department has also advised the 4/12
petitioner to appeal before the State Level Committee through proceedings dated 11.11.2022. Even then, the petitioner has not taken any steps to file an appeal before the appropriate Authority.
6. As per the guidelines issued for the implementation of New Health Insurance Scheme, 2021, the grievance redressal mechanism is as follows.
"15. Redressal of Grievances and Reimbursement of payment:
(1) Claims under clause-11 of these Guidelines for reimbursement of payments made by beneficiary to Hospital for Eligible Medical Expenses shall be submitted by the beneficiaries to the Grievance Redressal Officer (Joint Director of Medical and Rural Health Services) along with relevant documents and bills.
(2) Reimbursement claims can be submitted to Grievance Redressal Officer through registered post or in Person.
(3) Claim Documents should be sent to Grievance Redressal Officer within 30 days from the Date of Discharge.
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(4) Claim Forms prescribed by Insurance Company / TPA can be downloaded from designated website of the Insurance Company / TPA.
(5) Documents that need to submit for a hospitalisation reimbursement claim are:- (a) Original completely filled in Claim Form. (b) Covering letter stating complete address, contact numbers and email address (if available), along with Schedule of Expenses.
(c) Copy of the ID card or copy of Form prescribed in Annexure-III or ID card issued under NHIS, 2016 (if any).
(d) Copy of Discharge Summary.
(e) Copy of Hospital final bill.
(f) Numbered receipts for payments made to the hospital [at the time of submission of original submission].
(g) Copy of Complete breakup of the hospital bill.
(h) Copy of Investigations done with the respective reports.
(6) The original documents should be kept in safe custody of the Employees and their eligible 6/12
family members of Government Departments etc., as these shall be handed over to the Insurance Company at later stage.
(7) The Grievance Redressal Officer shall examine the claims to verify if the claims relate only to Eligible Medical Expenses and recommend to the District Level Empowered Committee for reimbursement of such sums of money that relate to Eligible Medical Expenses. In case of claims relating to Non-Network Hospital, he shall examine and submit to the District Level Empowered Committee with his opinion as to whether the claim relates to Emergency Care or treatment / surgery undergone following an Accident or nonemergency care. The Grievance Redressal Officer shall submit his report with his opinion to District Level Empowered Committee within a period of one month from the date of receipt of claim from the Beneficiary.
(8) The District Level Empowered Committee shall examine claims with reference to the recommendations and opinions of the Grievance Redressal Officer and approve all 7/12
such sums for reimbursement that it finds to be Eligible Medical Expenses, satisfying the requirements of clause-11 of these Guidelines within a period of one month from the date of receipt of the report from the Grievance Redressal Officer.
(9) Appeal against the claims of the District Level Empowered Committee shall lie with the State Level Empowered Committee within a period of one month from the date of receipt of copy of the Proceedings of the Committee.
(10) The sums determined by the District Level Empowered Committee / State Level Empowered Committee in any case not exceeding the applicable package rates specified in clause-11 of these guidelines. to be reimbursable shall be paid by the Insurance Company to the Beneficiary within a period of one month from the date of receipt of copy of the Proceedings of the Committee.
(11) In case, claim is denied, it should be ensured that the denial letter is sent quoting the reason for denial of claim to the Beneficiary.
(12) Any claim in deviation of the above 8/12
procedure for reimbursement is liable to be rejected.
(13) Any grievance / dispute arising out of the implementation of the Scheme remaining unresolved by the State Level Empowered Committee shall be preferred within fifteen days of award of State Level Empowered Committee to the High Level Empowered Committee.
(14) The Civil Courts situated in Chennai shall have exclusive jurisdiction over any grievance / dispute remaining unresolved by the above procedure.
(15) Nothing aforesaid, shall prejudice the rights of the Government of Tamil Nadu to approach any other forum for dispute resolution permissible under Law.
(16) The list of address of Grievance Redressal Officers and the address of District Level Empowered Committee, State Level Empowered Committee and High Level Empowered Committee are listed in Annexure - VII & VIII to these guidelines."
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7. Anyone aggrieved over the rejection of reimbursement claim has to follow the statutory procedures without knocking the doors of either the Insurance Company or the higher officials of the Insurance Company. Obviously, the petitioner's remedy lies before a different forum i.e., State Level Empowered Committee.
8. In view of the same, the writ petition is disposed of and the petitioner is at liberty to prefer an appeal before the State Level Empowered Committee and workout her remedy. No costs. Consequently, connected Miscellaneous Petition is closed. 15.04.2024 NCC: Yes/No Index : Yes/No Speaking/Non-Speaking order mbi 10/12
To 1.The Director, The Director of Medical and Rural Health Services, DMS Complex 361, Anna Salai, Chennai - 600 006. 2.The Commissioner, The Department of Treasuries and Accounts, 3rd Floor, Perasiriyar K.Anbazhagan Maaligai, No.571, Anna Salai, Nandanam, Chennai - 600 035.
3.The District Collector, The Collectorate, Madurai District.
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R.N.MANJULA, J.
mbi 15.04.2024 12/12